Director's Report to the National Advisory Council on Drug Abuse - February, 2009

Research Findings - Research on Behavioral and Combined Treatments for Drug Abuse

New Interview on Client Money Mismanagement Superior to Clinician Judgment

Dually diagnosed drug abusers often receive Social Security disability or public assistance. Money mismanagement is frequently reported as a difficulty by these clients and their treatment and service providers yet reliable measures of money mismanagement prior to this study have not existed. This is important because in the Veterans' Health Administration an assessment of money management ability may be used to make a determination of whether to assign a payee to the Veteran's money. This procedure reduces the Veteran's autonomy and should not be undertaken lightly. Moreover, assigning a representative payee to a capable client is a drain on taxpayer dollars. This study examined the reliability and validity of a new semi-structured interview measure of money mismanagement. The measure had excellent test-retest reliability but did not correlate well with clinician judgments of capability to manage funds. The structured interview correlated closely with the client's own assessment of money management skill and also with global assessment of functioning by clinicians. High reliability and construct validity suggest the new measure may have greater utility than clinician judgment for assessment of money management. Black, R.A., Rounsaville, B.J., Rosenheck, R.A., Conrad, K.J., Ball, S.A., and Rosen, M.I. Measuring Money Mismanagement among Dually Diagnosed Clients. Journal of Nervous and Mental Diseases, 196(7), pp. 576-579, 2008.

Gender Differences in Body Mass Index for Different Lifetime and Current Substance Use Diagnoses

Researchers have posited concerns about weight as both risk factors for initiation of substance use and for relapse to substance use but this relationship and its interaction with gender is poorly understood. This study analyzed data from the National Epidemiological Study on Alcohol and Related Conditions which included body mass index (BMI) and substance use disorder diagnoses for specific substances (both lifetime and past year) with the aim of understanding the relationship between these disorders, BMI and gender. Researchers did not find association between BMI and either past year or lifetime use of "any substance of abuse" (e.g., tallying across all substance categories). However, when alcohol and tobacco were dropped from the analysis, men but not women showed a negative association between past year substance abuse and obesity. When substances were analyzed separately there was no relationship between use of marijuana or cocaine by weight for either gender. There was a non-significant trend for increased lifetime risk of opioid use disorders in overweight women but not men. More research is needed to determine if this reflects post-cessation weight gain or higher vulnerability to opioids in overweight women. In overweight and obese men lifetime and past year nicotine addiction was significantly lower than for men with normal BMI. Overweight was significantly and positively associated with lifetime nicotine addiction in women possibly reflecting post-cessation weight gain in women than in men. Obesity was significantly and inversely associated with past-year nicotine dependence in women. In men, alcohol use disorders both past year and lifetime were correlated with higher BMIs. For women higher BMI did not relate to lifetime alcohol use disorder. Additionally obese women were statistically unlikely to have a past year diagnosis of alcohol dependence. This suggests that male alcoholics are at higher risk for weight gain and related consequences. It may indicate that women alcoholics may substitute calories from alcohol with calories from food. Overall this study is important because it suggests that a history of nicotine, alcohol, and possibly opioid use may have important long term consequences for body mass index that differs between men and women. Additionally it is possible that substance use histories are reflective of underlying differences in reward sensitivity or metabolism which predispose people both to certain drugs and to overeating and interact with gender because of physiological, hormonal or societal factors. More research is needed to determine how to address weight gain and obesity for male and female substance users. Barry, D. and Petry, N. Associations between Body Mass Index and Substance Use Disorders Differ by Gender: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Addictive Behavior, 34(1), pp. 51-90, 2009.

The purpose of this study was to evaluate the efficacy of an interactive, computer-based behavioral therapy intervention. Specifically, Dr. Bickel and colleagues computerized the community reinforcement approach (CRA) plus voucher-based contingency management model of behavior therapy. Participants were 135 volunteer adult outpatients who met DSM-IV criteria for opioid dependence. All participants received maintenance treatment with buprenorphine and were randomly assigned to one of three treatments: (1) therapist-delivered CRA treatment with vouchers, (2) computer-assisted CRA treatment with vouchers, or (3) standard treatment. Results showed the therapist-delivered and computer-assisted CRA plus vouchers interventions produced comparable weeks of continuous opioid and cocaine abstinence (M = 7.98 and 7.78, respectively), and significantly greater weeks of abstinence than the standard intervention (M = 4.69; p < .05). However, participants in the computer-assisted CRA condition had over 80% of their intervention delivered by an interactive computer program. The comparable efficacy obtained with computer-assisted and therapist-delivered therapy may enable more widespread dissemination of the evidence-based CRA plus vouchers intervention in a manner that is cost-effective and ensures treatment fidelity. Bickel, W.K., Marsch, L.A., Buchhalter, A.R., and Badger, G.J. Computerized Behavior Therapy for Opioid-Dependent Outpatients: A Randomized Controlled Trial. Experimental and Clinical Psychopharmacology, 16(2), pp. 132-143, 2008.

Pretreatment Brain Activation during Stroop Task is Associated with Outcomes in Cocaine-Dependent Patients

Cognitive behavioral and related therapies for cocaine dependence may enhance cognitive control over drug use behavior. This study was designed to examine the neural correlates of cognitive control as related to treatment outcomes for cocaine dependence. Twenty treatment-seeking cocaine-dependent individuals performed a Stroop color-word interference task while undergoing functional magnetic resonance imaging (fMRI) prior to initiating treatment. In this study, Dr. Brewer and colleagues from Yale found that during Stroop performance, cocaine-dependent patients activated brain regions similar to those reported in nonaddicted individuals, including the anterior cingulate cortex, dorsolateral prefrontal cortex, parietal lobule, insula, and striatum. Activations at treatment onset correlated differentially with specific outcomes: longer duration of self-reported abstinence correlated with activation of ventromedial prefrontal cortex, left posterior cingulate cortex, and right striatum; percent drug-free urine screens correlated with striatal activation; and treatment retention correlated with diminished activation of dorsolateral prefrontal cortex. A modest correlation between Stroop effect and treatment retention was found. These findings implicate neurocircuitry underlying cognitive control in behavioral treatment outcome and provide insight into the mechanisms of behavioral therapies for cocaine dependence. The authors suggest neural activation patterns during cognitive control tasks are more sensitive predictors of treatment response than behavioral measures. Brewer, J.A., Worhunsky, P.D., Carroll, K.M., Rounsaville, B.J., and Potenza, M.N. Pretreatment Brain Activation during Stroop Task Is Associated with Outcomes in Cocaine-Dependent Patients. Biological Psychiatry, 64(11), pp. 998-1004, 2008.

Computer-Assisted Delivery of Cognitive-Behavioral Therapy for Addiction: A Randomized Trial of CBT4CBT

There are a number of obstacles to delivering cognitive-behavioral therapy (CBT) and other empirically validated therapies in clinical practice, including limited training, supervision, and the relative complexity and cost of training clinicians in CBT. Drs. Carroll, Ball, and colleagues from Yale University evaluated the efficacy of a computer-based version of CBT for substance dependence. This was a randomized clinical trial in which 77 individuals seeking treatment for substance dependence at an outpatient community setting were randomly assigned to standard treatment or standard treatment with biweekly access to computer-based training in CBT (CBT4CBT) skills. Treatment retention and data availability were comparable across the treatment conditions. Participants assigned to the CBT4CBT condition submitted significantly more urine specimens that were negative for any type of drugs and tended to have longer continuous periods of abstinence during treatment. The CBT4CBT program was positively evaluated by participants. In the CBT4CBT condition, outcome was more strongly associated with treatment engagement than in treatment as usual; furthermore, completion of homework assignments in CBT4CBT was significantly correlated with outcome and a significant predictor of treatment involvement. These data suggest that CBT4CBT is an effective adjunct to standard outpatient treatment for substance dependence and may provide an important means of making CBT, an empirically validated treatment, more broadly available. Carroll, K.M., Ball, S.A., Martino, S., Nich, C., Babuscio, T.A., Nuro, K.F., Gordon, M.A., Portnoy, G.A., and Rounsaville, B.J. Computer-Assisted Delivery of Cognitive-Behavioral Therapy for Addiction: A Randomized Trial of CBT4CBT. American Journal of Psychiatry, 165 (7), pp. 881-888, 2008.

Enduring Effects of a Computer-Assisted Training Program for Cognitive Behavioral Therapy: A 6-Month Follow-Up of CBT4CBT

Following an initial randomized clinical trial to examine the efficacy of a six-module, multimedia computer-based version of CBT ("CBT4CBT") as an adjunct to standard outpatient treatment, Dr. Carroll and colleagues examined the durability of effects of CBT4CBT. Specifically, study participants were assessed 1, 3, and 6 months after the termination of study treatments in which they were assigned (treatment-as-usual [TAU] or TAU with bi-weekly access to CBT4CBT). Sixty of the 73 participants were reached for follow-up (82%); follow-up rates and availability of data were comparable across treatment conditions. Random effects regression analyses of use across time indicated significant differences between groups, such that those assigned to TAU increased their drug use across time while those assigned to CBT4CBT tended to improve slightly. The durability of the CBT4CBTeffect remained significant even after controlling for treatment retention, treatment substance use outcomes, and exposure to other treatment during the follow-up period. These data show strong support for the durability of effects from computer-assisted CBT, in that they were obtained even after controlling for important prognostic indicators. Additionally, this is the first study to demonstrate enduring effects of computer-assisted CBT on a behavioral indicator of outcome (urine specimens). CBT4CBT may be used in drug abuse treatment settings as an adjunct to standard treatment. Carroll, K.M., Ball, S.A., Martino, S., Nich, C., Babuscio, T.A., and Rounsaville, B.J. Enduring Effects of a Computer-Assisted Training Program for Cognitive Behavioral Therapy: A 6-Month Follow-Up of CBT4CBT. Drug and Alcohol Dependence, 2008 November 26. [Epub ahead of print].

Drug Abuse and Responsible Fathering: A Comparative Study of Men Enrolled in Methadone Maintenance Treatment

The purpose of this study was to examine ways that drug abuse contributes to the compromise of responsible fathering. Drs. McMahon, Winkel, and Rounsaville from Yale University identified dimensions of responsible fathering used to clarify ways that the fathering of 106 men receiving methadone maintenance treatment differed from that of 118 men living in the same community with no history of alcohol or drug abuse. Men who enrolled in the study completed two structured interviews and a battery of five self-report measures selected to document current and historical dimensions of responsible fathering. When the opioid-dependent fathers were compared to the other fathers, there were significant differences in economic resources to support family formation, patterns of pair-bonding, patterns of procreation, and parenting behavior. When fathering of the youngest biological child was examined, the opioid-dependent fathers confirmed few differences in historical dimensions of fathering, but they reported significant differences in current dimensions reflecting constricted personal definitions of the fathering role, poorer relationships with biological mothers, less frequent residence with the child, less frequent provision of financial support, less involvement in positive parenting, poorer appraisal of self as a father, and less satisfaction as a father. The findings highlight ways that drug abuse contributes to compromise of responsible fathering, and ways in which the drug abuse treatment system might better address parenting as a treatment issue for men. McMahon, T.J., Winkel, J.D., and Rounsaville, B. Drug Abuse and Responsible Fathering: A Comparative Study of Men Enrolled in Methadone Maintenance Treatment. Addiction, 103(2), pp. 269-283, 2008.

Although religious activity participation is often encouraged during treatment, little research exists on whether or how such participation might impact treatment outcomes. This study examined whether better outcomes were obtained by people who completed religious activity goals as part of two contingency management studies in which people received opportunities to draw for prizes in exchange for completing treatment goals they selected. Attending a religious service was by far the most frequently chosen type of religious activity. Overall those completing 3 or more religious activities had better treatment attendance, longer durations of continuous abstinence during treatment and a greater proportion of drug negative urine samples even when controlling for total goals completed. These findings are important because they suggest one class of activities (religious event participation) that may have an important impact on treatment outcome. Results should be interpreted with caution because religious activities are often the only socially inclusive activities available to drug abusers to participate in and thus it is not clear whether religious activities or general social activities might convey similar benefits. Additionally, it is possible that these findings reveal that it is an ability to participate in religious activities rather than the spiritual or social nature of the activities themselves which are important. Religious activity participation like treatment requires coordination of transportation and timely meeting attendance, attention to a lecture format, and a willingness to follow rules, etc. More research is needed to determine whether religious activities themselves confer benefits to abstinent lifestyles or whether people who have the skills to abstain from drugs are simply also likely to become engaged in non-drug related social activities. Petry, N., Lewis, M., and Ostvik-White, E. Participation in Religious Activities during Contingency Management Interventions is Associated with Substance Use Treatment Outcomes. American Journal of Addiction, 17(5), pp. 408-413, 2008.

Voucher Reinforcement Does Not Improve Abstinence Outcomes In Drug Court

Drug courts provide judicial oversight and treatment to non-violent offenders but it is not known whether application of an efficacious behavioral treatment approach such as voucher reinforcement of abstinence, or voucher reinforcement of prosocial activities might improve on treatment outcomes obtained for community drug court participants. This study examined whether community drug court participants engaged in outpatient "drug free" treatment (not methadone maintenance) primarily with methamphetamine use disorders would receive benefits over and above the benefits of methadone from either $10.00 voucher payments for successive drug free urine submissions or for completion of prosocial behaviors thought to influence recovery. Participants in a California drug court (N=163) who were sent to the Matrix treatment program, a comprehensive outpatient treatment program, were randomly assigned to drug court plus treatment, drug court plus treatment plus vouchers for urine submission without any contingency, drug court plus treatment with vouchers for abstinent urines and prosocial behavior and drug court plus treatment with vouchers for prosocial behaviors only. The prosocial behavior contingencies involved client determined counselor approved weekly treatment goals. No differences emerged between groups on during treatment measures of retention in treatment, drug use, or psychosocial functioning relative to the standard drug court treatment condition. This is important because virtually all other tests of voucher reinforcement have shown the treatment to impact outcomes. There are several possible reasons for this surprising finding including a ceiling effect from the Matrix standard treatment, which is evidence based and the judicial rewards and sanctions already used in drug court as well as the fact that the value of the vouchers used in the program remained a consistent relatively low flat rate in contrast with other models that increased in values with increasing abstinence duration. Prendergast, M.L., Hall, E.A., Roll, J., and Warda, U. Use of Vouchers to Reinforce Abstinence and Positive Behaviors among Clients in a Drug Court Treatment program. Journal of Substance Abuse Treatment, 35(2), pp. 125-136, 2008.

This study examined the efficacy of individual cognitive behavioral therapy (CBT) and multidimensional family therapy (MDFT) for adolescents in a community-based drug abuse clinic. A total of 224 youth, primarily male (81%), African American (72%), from low-income single-parent homes (58%) with an average age of 15 years were recruited into the study. All youth were drug users, with 75% meeting DSM-IV criteria for cannabis dependence and 13% meeting criteria for abuse. A 2 (treatment condition) x 4 (time) repeated-measures intent to-treat randomized design was applied, and data were gathered at baseline, termination, and at 6 and 12 months post-termination. Both treatments produced significant decreases in cannabis consumption and slightly significant reductions in alcohol use, but there were no treatment differences in reducing frequency of cannabis and alcohol use. Significant treatment effects were found favoring MDFT on substance use problem severity, other drug use and minimal use (zero or one occasion of use) of all substances, and these effects continued to 12 months following treatment termination. Consistent with previous controlled trials, MDFT is distinguished by the sustainability of treatment effects. Liddle, H.A., Dakof, G.A., Turner, R.M., Henderson, C.E., and Greenbaum, P.E. Treating Adolescent Drug Abuse: A Randomized Trial Comparing Multidimensional Family Therapy and Cognitive Behavior Therapy. Addiction, 103(10), pp. 1660-1670, 2008.

Treatment Adherence, Competence, and Outcome in Individual and Family Therapy for Adolescent Behavior Problems

This study examined the impact of treatment adherence and therapist competence on treatment outcome in a controlled trial of individual cognitive behavioral therapy (CBT) and multidimensional family therapy (MDFT) for adolescent substance use and related behavior problems. Participants included 136 adolescents (62 CBT, 74 MDFT) assessed at intake, discharge, and 6-month follow-up. Observational ratings of adherence and competence were collected on early and later phases of treatment (192 CBT sessions, 245 MDFT sessions) by using a contextual measure of treatment fidelity. Adherence and competence effects were tested after controlling for therapeutic alliance. In CBT only, stronger adherence predicted greater declines in drug use (linear effect). In CBT and MDFT, (a) stronger adherence predicted greater reductions in externalizing behaviors (linear effect) and (b) intermediate levels of adherence predicted the largest declines in internalizing behaviors, with high and low adherence predicting smaller improvements (curvilinear effect). Therapist competence did not predict outcome and did not moderate adherence-outcome relations; however, competence findings are tentative due to relatively low inter-rater reliability for the competence ratings. Hogue, A., Henderson, C.E., Dauber, S., Barajas, P.C., Fried, A., and Liddle, H.A. Treatment Adherence, Competence, and Outcome in Individual and Family Therapy for Adolescent Behavior Problems. Journal of Consulting and Clinical Psychology, 76(4), pp. 544-555, 2008.

Predictors of Homelessness Among Street Living Youth

While few studies have identified predictors of exiting homelessness among adults, even fewer studies have attempted to identify these predictors among homeless youth. The current study explored predictors of change in homelessness among 180 homeless youth between the ages of 14 and 22, recruited through an urban drop-in center. All youth were assessed at baseline, 3 and 6 months. The sample included 118 males and the reported ethnicity included Latino (n = 54), Anglo (n = 73), Native American (n = 24), African American (n = 6) and mixed ethnicity or "other" (n = 23). Four distinct patterns of change in homelessness were identified among youth which included those who (1) had fairly low rates of homelessness at each follow-up point, (2) started in the mid-range of homelessness, increased at 3 months and sharply declined at 6-months (MHL), (3) reported high rates of homelessness at baseline and low rates at each follow-up point (HLL), and finally, (4) remained consistently homeless across time (HMH). These patterns of change were most strongly predicted by social connections and engagement in HIV risk behaviors. The author concludes that findings from this study suggest that developing trust and linkages between homeless youth and service providers may be a more powerful immediate target of intervention than targeting child abuse issues, substance use and mental health problems. Slesnick, N., Bartle-Haring, S., Dashora, P., Kang, M.J., and Aukward, E. Predictors of Homelessness Among Street Living Youth. J. Youth Adolesc., 37(4), pp. 465-474, 2008.

Consequences of Misspecifying the Number of Latent Treatment Attendance Classes in Modeling Group Membership Turnover within Ecologically Valid Behavioral Treatment Trials

Historically, difficulties in analyzing treatment outcome data from open-enrollment groups have led to their avoidance in use in federally funded treatment trials despite the fact that 79% of treatment programs use open-enrollment groups. Recently, latent class pattern mixture models (LCPMM) have shown promise as a defensible approach for making overall (and attendance-class-specific) inferences from open enrollment groups with membership turnover. Morgan-Lopez and Fals-Stewart present a statistical simulation study comparing LCPMMs to longitudinal growth models (LGM) to understand when both frameworks are likely to produce conflicting inferences concerning overall treatment efficacy. LCPMMs performed well under all conditions examined; meanwhile, LGMs produced problematic levels of bias and Type I errors under certain conditions. This study highlights key concerns about using LGM for open-enrollment data: treatment effect overestimation and advocacy for treatments that may be ineffective in reality. Morgan-Lopez, A.A. and Fals-Stewart, W. Consequences of Misspecifying the Number of Latent Treatment Attendance Classes in Modeling Group Membership Turnover within Ecologically Valid Behavioral Treatment Trials. Journal of Substance Abuse Treatment, 35, pp. 396-409, 2008.

Physical Activity as a Strategy for Maintaining Tobacco Abstinence

Dr. Prochaska and colleagues from UCSF conducted this randomized controlled trial to examine (1) the impact of an extended relapse prevention program on increasing moderate to vigorous physical activity in adults enrolled in a tobacco cessation treatment trial; (2) whether changes in activity were associated with sustained abstinence from smoking; and (3) mechanisms by which activity may support sustained abstinence from smoking. Participants were 407 adult smokers receiving a 12-week group-based smoking cessation treatment with bupropion and nicotine patch. At week 12, participants were randomized to no further treatment or to 40 weeks of bupropion or placebo with or without an 11-session relapse prevention intervention of which 2 sessions focused on physical activity. Participants receiving the physical activity intervention (n=163) received a pedometer, counseling to increase steps 10% biweekly towards a 10,000 steps/day goal, and personalized reports graphing progress with individualized goals. The results showed that participants receiving the physical activity intervention significantly increased their activity relative to control participants. Pedometer step counts also increased significantly although pedometer monitoring dropped off. Controlling for treatment condition, increased physical activity predicted sustained smoking abstinence at week 24. Among participants with sustained abstinence, increased activity was associated with increased vigor and decreased perceived difficulty with staying smoke-free. The authors conclude that the addition of a low cost, two session physical activity program to a smoking cessation intervention served to increase participants' physical activity with changes predictive of sustained abstinence at 24 weeks. The timing of the physical activity sessions, promotion of lifestyle activity of moderate intensity, and tailoring of step goals to participants' baseline activity levels are factors that likely contributed to the significant changes observed. Prochaska, J.J., Hall, S.M., Humfleet, G., Munoz, R.F., Reus, V., Gorectki, J., and Hu, D. Physical Activity as a Strategy for Maintaining Tobacco Abstinence: A Randomized Trial. Preventive Medicine, 27, pp. 215-220, 2008.

Women's Interest in Treatment to Stay Abstinent from Cigarettes Postpartum

Dr. Michelle Levine at the Western Psychiatric Institute and Clinic in Pittsburgh conducted this study to determine the acceptability of a postpartum smoking relapse prevention intervention and the appeal of strategies to address concerns about mood, stress and weight to prevent postpartum relapse. A survey about relapse prevention program modalities, topics and barriers to treatment was administered to 36 women who had quit smoking during pregnancy and either remained abstinent or relapsed within the first year postpartum. Survey results of women who had and had not relapsed to smoking were compared. The findings showed that both groups endorsed the opportunity to talk with a counselor about relapse prevention and did not differ in their endorsement of treatment modalities. Discussing mood, stress, and weight concerns were endorsed by both groups of women, but those who had relapsed were more likely to endorse stress management as an intervention topic. Those who had relapsed were more likely to endorse the use of pharmacologic aids than were those who had remained abstinent. According to Dr. Levine, the data suggest that postpartum women would find a smoking relapse prevention program that includes group and individual counseling and the use of strategies to address mood, stress, and weight concerns acceptable. Levine, M.D. Women's Interest in Treatment to Stay Abstinent from Cigarettes Postpartum. Women's Health Issues, 18(5), pp. 381-6, 2008. Epub 2008 November 5.

Dual-Focus Mutual Aid for Co-Occurring Disorders

Double Trouble in Recovery (DTR) is a dual focus mutual aid group adapted from the 12-steps of AA, which aims to assist individuals with co-occurring substance use and psychiatric disorders. Dr. Magura conducted this quasi-experimental study to determine whether adding DTR mutual aid to a day treatment psychiatric program that primarily serves patients with co-occurring disorders improves patient outcomes. Patient outcomes in the same psychiatric day treatment program were compared for two consecutive admission cohorts. The first cohort did not have DTR available while the second cohort was exposed to DTR after it was established at the program. Both cohorts were assessed at program admission and at six-month follow-up. The post-DTR cohort as compared with the pre-DTR cohort had significantly fewer days of alcohol and drug use, more frequent traditional 12-step groups outside of the program and higher psychiatric medication adherence. There were no differences in psychiatric symptoms or program retention, however. This study demonstrates the benefits of introducing 12-step, dual-focus mutual aid into psychiatric treatment programs that serve patients with co-occurring disorders. Magura, S., Rosenblum, A., Villano, C.L., Vogel, H.S., Fong, C. and Betzler, T. Dual-Focus Mutual Aid for Co-Occurring Disorders: A Quasi-Experimental Outcome Evaluation Study. The American Journal of Drug and Alcohol Abuse, 34, pp. 61-74, 2008.

Extended Cognitive Behavior Therapy for Cigarette Smoking Cessation

Dr. Killen and colleagues at Stanford University School of Medicine conducted this randomized clinical trial to determine the efficacy of extended cognitive behavior therapy (CBT) for smoking cessation. During an open label trial 304 participants were randomized and received bupropion SR, nicotine patch and individual CBT. During extended treatment, half received additional CBT and half received telephone-based general supportive therapy. Findings show that at week 20, CBT produced a higher point prevalence abstinence rate: 45% vs. 29%, p=.006; at 52 weeks the difference in abstinence rates (31% vs. 27%) was not significant. History of depression was a moderator of treatment. Those with a positive history had a better treatment response at 20 weeks when assigned to the less intensive telephone support therapy (p

Adverse Events in an Integrated Trauma-focused Intervention for Women in Community Substance Abuse Treatment

A substantial number of women who enter substance abuse treatment have a history of trauma and meet criteria for posttraumatic stress disorder (PTSD). Fear regarding the extent to which PTSD treatment can evoke negative consequences remains a research question. This study explored adverse events related to the implementation of an integrated treatment for women with trauma and substance use disorder (Seeking Safety) compared with a nontrauma-focused intervention (Women's Health Education). Three hundred fifty-three women enrolled in community substance abuse treatment were randomized to one of the two study groups and monitored weekly for adverse events. There were no differences between the two intervention groups in the number of women reporting study-related adverse events. Implementing PTSD treatment in substance abuse treatment programs appears to be safe, with minimal impact on intervention-related adverse psychiatric and substance abuse symptoms. The authors do note, however, that more research is needed on the efficacy of such interventions to improve outcomes of PTSD and substance use. Killeen T., Hien, D., Campbell, A., Brown, C., Hansen, C., Jiang, H., Kristman-Valente, A., Neuenfeldt, C., Rocz-de la Luz, N., Sampson, R., Suarez-Morales, L., Wells, E., Brigham, G., and Nunes, E. Adverse Events in an Integrated Trauma-focused Intervention for Women in Community Substance Abuse Treatment. Journal of Substance Abuse Treatment, 35(3), pp. 304-311, 2008.

Although it is quite common, the use of cash incentives to compensate drug-addicted participants is controversial. This is particularly true given concerns that cash incentives might precipitate or cause relapse, as is commonly believed. Dr. Brady and colleagues examined whether cash as compared to money order compensation influenced drug use among 34 non-treatment-seeking, cocaine-dependent individuals. Consistent with past evidence, results did not suggest that form of compensation was associated with either the likelihood of continued cocaine use or the dollar amount of cocaine consumed after participation. In sum, the data did not support commonly held concerns that cash incentives increase the risk of relapse following research participation. Dempsey, J.P., Back, S.E., Waldrop, A.E., Jenkins, L., and Brady, K.T. The Influence of Monetary Compensation on Relapse among Addicted Participants: Empirical vs. Anecdotal Evidence. American Journal of Addiction, 17(6), pp. 488-490, 2008.

Early Life Trauma and Sensitivity to Current Life Stressors in Individuals with and without Cocaine Dependence

This study investigated the link between exposure to early life trauma, sensitivity to current daily stressors, and cocaine dependence. Individuals (with or without cocaine dependence) completed assessments of early life trauma as well as current daily stressors. In comparison to controls, cocaine-dependent individuals reported almost twice as many daily hassles and perceived those hassles more negatively. In addition, among participants with cocaine dependence, there existed a significant relationship between exposure to early life trauma and negative perception of current daily hassles, while no such relationship was observed for participants without cocaine dependence. These data suggest that adverse childhood events may lead to an altered view of the environment that contributes to increased irritability with daily life events among cocaine-dependent individuals. Back, S.E., Brady, K.T., Waldrop, A.E., Yeatts, S.D., McRae, A.L., and Spratt, E. Early Life Trauma and Sensitivity to Current Life Stressors in Individuals with and without Cocaine Dependence. American Journal of Drug and Alcohol Abuse, 34(4), pp. 389-396, 2008.

Impact of Posttraumatic Stress Disorder on Early Smoking Relapse and Relapse During a Self-Guided Quit Attempt Among Community-Recruited Daily Smokers

The present investigation examined whether daily smokers with posttraumatic stress disorder (PTSD), as compared to daily smokers with either anxiety symptoms or no psychiatric diagnoses, exhibited less success in the early phases of a self-guided smoking quit attempt. Participants were 140 adult daily smokers; approximately one-third of the sample met criteria for current PTSD (n = 47), one-third met criteria for other current anxiety disorders (without PTSD; n = 33), and one-third did not meet criteria for any current Axis I disorder (n = 60). Consistent with the authors' predictions, participants with PTSD (as compared to membership in the other anxiety disorders group and the group with no current Axis I psychopathology) was associated with increased risk of lapse (smoking any amount following quit day) during the first week after treatment ended. In addition, daily smokers with PTSD and other anxiety disorders were at significantly increased risk of relapse (smoking at least 5 cigarettes per day on at least three consecutive days following quit day) during the first week after treatment ended. These data provide novel and provocative evidence that PTSD, and perhaps anxiety disorders more generally, may be important factors in reducing the odds of successful unaided quit attempts in the early phases of cessation. Zvolensky, M.J., Gibson, L.E., Vujanovic, A.A., Gregor, K., Bernstein, A., Kahler, C., Lejuez, C.W., Brown, R.A., and Feldner, M.T. Impact of Posttraumatic Stress Disorder on Early Smoking Relapse and Relapse during a Self-Guided Quit Attempt among Community-Recruited Daily Smokers. Nicotine & Tobacco Research, 10(8), pp. 1415-1427, 2008.

Changes in Psychiatric Patients' Thoughts about Quitting Smoking during a Smoke-Free Hospitalization

Investigators from UCSF conducted this study to examine whether smoking abstinence, as a consequence of psychiatric hospitalization in a smoke-free facility, was associated with changes in participants' thought about quitting smoking. Participants (N=100) on an inpatient psychiatry unit, were asked about their reported desire to quit smoking, their expectancy of success, their anticipated difficulty with quitting and their smoking abstinence goal. Assessments were conducted at hospital intake and shortly before hospital discharge. Follow-up assessments were conducted by phone at 1 week, 1 month, and 3 months post-hospitalization to measure smoking behavior. Participants were offered NRT to manage withdrawal, but were offered no other cessation treatment. From admission to discharge, participants reported an increased expectancy of success with quitting and a decreased expectancy of difficulty with staying quit. They also were more likely to endorse a smoking-related goal. The results suggest that by the time of their hospital discharge, patients may have increased their readiness for treatment, as evident by significantly greater confidence in and commitment to abstinence. Patients demonstrated a positive transformation in their thoughts about abstinence, which had beneficial effects on their subsequent smoking behavior in terms of reduction in the number of cigarettes smoked and later attempts at quitting. Shmueli, D., Fletcher, L., Hall, S.E., Hall, S.M., Prochaska, J.J. Changes in Psychiatric Patients' Thoughts about Quitting Smoking during a Smoke-Free Hospitalization. Nicotine & Tobacco Research, 10(5), pp. 875-881, 2008.

Dr. Sharon Allen and colleagues at the University of Minnesota conducted this study to characterize premenstrual symptomatology, mood and smoking withdrawal during the follicular and luteal phases under conditions of ad libitum smoking; as well as actual smoking behavior, and to determine whether phase-related variability in these measures influences likelihood of completing the protocol and smoking cessation outcome. During ad libitum smoking, all measures of premenstrual symptomatology, as well as some measures of mood and smoking withdrawal, were significantly higher during the luteal phase. Moreover, phase-related variability in premenstrual symptoms and urge to smoke were associated with relapse. These findings support the inference that sex hormones influence smoking cessation outcome. This knowledge may contribute to the development of more rational and effective smoking cessation interventions for women. Allen, S., Allen, A., and Pomerleau, C.S. Influence of Phase-Related Variability in Premenstrual Symptomatology, Mood, Smoking Withdrawal, and Smoking Behavior During Ad Libitum Smoking, on Smoking Cessation Outcome. Addictive Behaviors, 34, pp. 107-111, 2009.